“We’re ready for this baby to get here,” said a very pregnant Caitlin Coe.

Sharon Foster, left, an Advanced Practice Registered Nurse midwife at Associates in Women’s Health, meets with Caitlin Coe and her 21-month-old daughter, Mackenzie. Coe is set to give birth to another daughter in a few weeks, and Foster delivered Mackenzie. The toddler goes with her mother to all of her doctor’s visits and likes to listen to the baby’s heartbeat and measure her mother’s belly. (May 27, 2014)
The Wichita Eagle

“We’re ready for this baby to get here,” said a very pregnant Caitlin Coe.

Coe, whose second child is due June 10, plans to have Sharon Foster deliver the baby. That’s after being pleased with Foster’s care during the delivery of Coe’s daughter Mackenzie nearly two years ago.

“We built a great relationship with her, and I felt like she had a great understanding of what we wanted, and so it helped her guide us through the birth process,” said Coe during an appointment with Foster earlier this week. As she talked, 21-month-old Mackenzie held a device to her mother’s stomach to hear the heartbeat of her little sister.

Foster, who works at Associates in Women’s Health, is the only Advanced Practice Registered Nurse midwife who delivers babies at Wichita hospitals.

She is one of more than 4,000 Advanced Practice Registered Nurses, or APRNs, in Kansas pushing for independent practice from physicians.

For the last six years, APRNs have been trying to get legislation passed at the state level that would eliminate what is known as a “collaborative practice agreement,” which requires APRNs to sign an agreement with a physician so that they can see patients.

Nurses say they would continue treating patients the way they do currently without having to find – and often pay – a collaborating physician.

“I don’t want to be a doctor. We’re not. We’re just an adjunct to health care. People need to have options and access to providers that they choose,” Foster said.

But some doctors say that eliminating the agreement could put patients at risk.

“We find APRNs very valuable and an important piece of how we take good care of patients, but we’re concerned about the lack of any sort of collaborative agreement or oversight,” said Donna Sweet, a Wichita physician who specializes in the care of HIV-positive and AIDS patients and is president of the Medical Society of Sedgwick County.

She noted that APRNs have significantly less training than physicians and said that eliminating the oversight “would be leaving the health of Kansans in the hands of people perhaps not as able as physicians.”

A bill was introduced in the Legislature earlier this year to eliminate the agreements, but it was not given a hearing. So it essentially died in committee.

In addition to eliminating the collaborative practice agreements, the bill would have lengthened the time after becoming a nurse practitioner that individuals would have to train before gaining prescribing privileges.

Nurse practitioners are allowed access to patients without a collaborating physician in 19 states and the District of Columbia, according to the American Association of Nurse Practitioners. Many of those are largely rural and in the western half of the U.S.

APRNs require additional training beyond a four-year bachelor’s degree. After getting their bachelor’s, they have to take graduate-level classes and pick an area in which to practice: midwifery, pediatrics, acute care, anesthesiology or psychiatric care. Some APRNs go on to get a doctorate.

They can prescribe medication, diagnose patients, prescribe other treatments and make referrals to physicians, and those things wouldn’t change by eliminating collaborative agreements, said Michelle Knowles, an APRN in Hays who has been practicing in rural areas for nearly 20 years.

“It is drilled into us in school where our boundaries are, so if it’s anything past that, we refer and consult and collaborate,” said Knowles, who is also the Kansas representative for the American Association of Nurse Practitioners and helped draft the language of the most recent APRN bill.

Rural challenges

Access to medical care can be a challenge for rural Kansans, and APRNs argue that if they can practice independently they can help improve access to care.

Knowles says there is already a shortage of physicians in rural areas and APRNs can help fill that need.

“This gives us the ability to work in areas where maybe no physicians practice,” Knowles said. “Some people have to get physicians to sign an agreement that may be 200 miles away.”

But Sweet disagrees.

“They often say they go to rural areas, but facts have not borne that out in Kansas or states that have made independent practice legal,” said Sweet, who employs two nurse practitioners at her office in Wichita.

She says patient access is important, but so is having the most qualified provider give care.

Growing field

From 2012 to 2013, the number of APRNs in Kansas grew from 3,865 to 4,116, according to the Kansas Board of Nursing. About 450 of those APRNs are in Sedgwick County.

“The workforce is there; we just need to ensure that we are using them to the full extent of their education and training and not putting up unnecessary roadblocks,” Knowles said.

Other states with fewer restrictions are recruiting APRNs from states like Kansas, she said.

Rae Lyn Mefford is an APRN and owner of Advanced Mobile Healthcare, which visits patients who can’t leave their homes. She started the business a couple of years ago after winning $10,000 from Wichita State’s Center for Entrepreneurship. The business has grown to 11 total employees – a physician partner, nurse practitioners and support staff who do about 2,000 patient visits a year.

But as part of the agreement with the physician, the physician has part ownership and gets 5 percent of the business’ profits, Mefford said.

“First, finding someone who would even (collaborate) in the first place is difficult. Second, it just increases the cost of running the business because you’re having to pay this additional expense,” Mefford said.

Mefford says she knows other APRNs who pay between $500 and $1,900 a month to a physician so they can practice.

“That’s what creates the barrier for APRNs to open their own practices and be business owners,” she said. “I know other nurse practitioners that say if this law is passed, they would like to open their own clinic.”

Discussion continues

The Kansas Medical Society, a statewide physician group, has created a committee to work with APRNs to discuss the issue of independent practice, Sweet said. The group had its first meeting about a month ago.

“We started a discussion, and it’s certainly not over,” Sweet said. “The Kansas Legislature didn’t really want to be in the middle of this and told us to get together and discuss it. … What we would hope to achieve is a middle ground discussion or arrangement that would not require changes to the law at this point.”

But Knowles says she doesn’t think APRNs will give up that easily on the idea of changing the law.

“If there was some way we could fix it without changing the law, we would have done that years ago,” Knowles said. “The problem can’t be fixed without changing the law.”